- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $318.75 / $502.03 / $1,124.00
| Facility | | $318.75 | $502.03 | $1,124.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $318.75 / $318.75 / $425.00
| Professional | | $318.75 | $318.75 | $425.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $510.00 / $706.00 / $1,000.00
| Facility | | $510.00 | $706.00 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $311.38 / $591.61 / $643.54
| Professional | | $311.38 | $591.61 | $643.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,023.01 / $1,023.01 / $1,023.01
| Facility | | $1,023.01 | $1,023.01 | $1,023.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,366.30 / $1,471.54 / $1,471.54
| Professional | | $1,366.30 | $1,471.54 | $1,471.54 |